All proposals submitted in response to this Request shall be ...

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C. PARTNERSHIP OR L.L.C.The business address is:Telephone:Fax:Website or Email Address:The partners or members are as follows: (Attach additional sheets if necessary)(Name, Home Address and Telephone)(Name, Home Address and Telephone)(Name, Home Address and Telephone)D. INDIVIDUAL PROPRIETORSHIPThe business address isTelephone:Fax:My home address isTelephone:Fax:Email or website:SECTION 2. NON-COLLUSION STATEMENTA. This proposal, bid or contract is made without any connection or common interestin the profits with any other person other than the Vendor except as listed on aseparate attached sheet to this affidavit.Check One:Others Interested in ContractNoneD-5 01/09
B. No department director or any employee or any officer of the City of Champaignhas any financial interest, directly or indirectly, in the award of this contractexcept as listed on a separate attached sheet to this affidavit.C. That the Contractor/Vendor is not barred from bidding on any contract, if bidding processwas used) as a result of violation of 720 ILCS 5/33E-3 and 5/33E-4 (Bid Rigging or BidRotating).SECTION 3. DRUG FREE WORKPLACE AND DELINQUENT ILLINOIS TAXESSTATEMENTThe undersigned states under oath that the Contractor/Vendor is in full compliance with theIllinois Drug Free Workplace Act, 30 ILCS 580/1. The undersigned also states under oath andcertifies that Contractor/Vendor is not delinquent in payment of any tax administered by theIllinois Department of Revenue except that the taxes for which liability for the taxes or the amountof the taxes are being contested, in accordance with the procedures established by theappropriate Revenue Act; or that the Vendor has entered into an agreement(s) with the IllinoisDepartment of Revenue for the payment of all taxes due and is in compliance with theagreement.SECTION 4. FAMILIARITY WITH LAWS STATEMENTThe undersigned, being duly sworn, hereby states that the Contractor/Vendor and its employeesare familiar with and will comply with all Federal, State and local laws applicable to the project,which may include, but is not limited to, the Prevailing Wage Act and the Davis-Bacon Act.CONTRACTOR/VENDOR_______________________________SignaturePrinted Name:Title:SUBSCRIBED and SWORN to before me this ____ day of _______________, 20___.________________________________Notary PublicMy Commission Expires: _______________________D-5 01/09
Page 2: All proposals submitted in response
Page 5: G. Section and subsection numbering
Page 9: 1.12 Acceptance of Proposal Content
Page 12 and 13: materials, supplies, and equipment
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Page 32: DUAL REPRESENTATION AFFIDAVIT(Note:

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